Latest / Behind The Knife: The Surgery Podcast / Surgical Endoscopy Series Ep. 5: Novel Endosurgical Techniques

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Surgical Endoscopy Series Ep. 5: Novel Endosurgical Techniques · Behind The Knife: The Surgery Podcast

• BTK Surg Endo Novel Techniques === Speaker: [00:00:00] Welcome back, and thanks for tuning in to our fifth episode in the Surgical Endoscopy series. Um, in this episode, our focus is going to be on novel surgical endoscopy techniques, or at least those that, um, we believe might be, uh, novel to the listeners of this podcast and, and less well-known overall. So we'll start off by a brief round of introductions, um, in standard fashion. Um, we are lucky enough to have the exact same crew as last time, and I had a very much had fun on the last episode. This is a group of, uh, four of us, uh, youngish surgeons. Um, all of us come from a sim- similar surgical lineage. Um, did, uh, minimally invasive surgery fellowships at Endeavor Health in Evanston, Illinois. For a brief reintroduction, I'm Sully Uso. I am an assistant professor at Dell Medical School at the University of Texas at Austin. Um, I specialize in minimally invasive surgery there, um, and primarily abdominal wall reconstruction, help run the Texas Center for Hernia and Abdominal Wall Surgery. Our senior surgeon, if you can call him that, um, is Dr. [00:01:00] Mason Hedberg. He's the mad scientist. Dr. Hedberg, uh, is a minimally invasive surgeon who helped train me. Um, he's still at Endeavor Health, um, and specializes in foregut surgery and surgical endoscopy. Um, he's best known for his work with patients that have gastroparesis and functional GI disorders, um, and is a real innovator in this space, I think somebody that we're gonna hear more and more from over the years. Um, and then we have Dr. Trevor Crafts. Dr. Crafts has been here with us, um, since our first episode on surgical, uh, endoscopy series. He is at the Rocky Mountain VA affiliated with the University of Colorado in Denver, um, where he is a, a general minimally invasive surgeon there. And then last but not least Dr. Zach Callahan. Uh, Dr. Callahan's a private practice, uh, minimally invasive, uh, surgeon and surgical endoscopist at Nashville, Tennessee. So very excited to have everybody. Um, so gentlemen, let's not waste any time, and, uh, get into some, uh, procedures and topics that might be, uh, unchartered territory, and hopefully, uh, we'll learn something [00:02:00] along the way. I will say that for the purposes of this episode, we'll be focusing, um, mostly on foregut, uh, surgery-related topics since that's a shared collective focus of our group. But, uh, Mason Hedberg, uh, let's begin with you. Um, and I know this is a topic that is near and dear to you which is antireflux mucosectomy or antireflux mucosal ablation, abbreviated ARMS and ARMA respectfully. What do you got for us? Speaker 2: All right. Thanks very much, Sully. So yeah, I think just to kind of zoom out a little bit in terms of endoscopic anti-reflux procedures, uh, these ARMS and ARMA are probably the most common currently. Uh, but in the past there were things like Stretta, which is using radiofrequency ablation at the LES, and then, uh, TIF, which is the incisionless fundoplication. And all of these, you know, those require some specialized devices. The ARMS and ARMA are nice because you can do them with equipment that are usually, that's already available in most GI labs. None of [00:03:00] these are very good if there's a hiatal hernia. So when we're working patients up, uh, usually, you know, people will do it up to a two centimeter hernia. But like, if it's a little slider, uh, if it's a real hernia, you know, three centimeters, four centimeters, these procedures probably are not gonna work, and they're not indicated. Uh, you just gotta get in there and fix the hernia. So the first one, the way this was described by Dr. Inoue in two thousand and fourteen, it was actually incidental. So he was doing a circumferential ESD of the distal esophagus for nodular Barrett's, and after that patient had healed, his GERD was gone. So it's, you know, kind of one of these eureka moments. Um, but he realized that you could do a resection of the, on the cardio side of the stomach just across the Z-line, um, and the s- you know, subsequent scarring would tighten up their Hill grade a little bit. I think that's the easiest way to think about this. You see someone has a Hill grade II or III. There's no substantial hernia. You can do these procedures to try to snug up, uh, the GE junction [00:04:00] around the scope. So ARMS is, uh, with the mucosectomy. Uh, there's two ways you can do that, either a cap EMR when the, the other one is just a snare EMR, I think, where you suck in a little bit of the mucosa and kind of grab it with the hot snare. Um, the full cap is where you pull in a bu- bigger piece of mucosa and then drop a band on it. Um, and then you can kind of take off bigger chunks of mucosa at a time. Um, so for this pattern, what you're trying to do, it's kind of described as a butterfly, where you're removing two big pieces of mucosa on either side of the GE junction, sparing a little bit on the greater and lesser curves. Um, and that was a modification, uh, Dr. Inoue described later. Uh, he realized he was having some dysphagia as, um, people healed this down, and leaving those little areas prevented dysphagia. ARMS, uh, or excuse me, ARMA is the ablation, um, and essentially the same pattern. You're doing these butterfly wings, but, um, instead of removing the mucosa, you're lifting the mucosa [00:05:00] first and then ablating it with relatively high energy. Uh, so it's usually fifty or sixty watts with the argon plasma coagulation. Um, so at that, with that amount of energy, you're really destroying the mucosa, but then the lift is protecting the deeper muscle layers to avoid a deeper injury Zach, I know you do these procedures as well. Any technical pearls you would, uh, like to describe? Speaker 3: Well, I think first, like, can we just talk about the concept of doing a circumferential ESD at the g- you know, like when Dr. Inoue stumbled upon this. Like, doing a, an ESD circumferentially at the GE junction, it's, like, basically impossible. So, like, I just kinda remind myself that the Japanese guys are just doing some crazy endoscopic stuff. But- Speaker: Better Speaker 3: than me ... in terms of technical pearls, I, I don't know about their pearls, but just mistakes I've made, and this is true of all EMR, but I have a great video of us getting just, it was a bad lift, and it was a bad band, and we burned it anyways. And, uh, you can end up with a full thickness hole. And just like I was joking about the ESD [00:06:00] being hard up there, closing a full thickness hole up there is really hard. Um, so that's kinda the, the big one. And then certainly, I, I, I think, you know, this concept of the butterfly, whether you're doing ARMS or ARMA, is, is important to leave those strips of intact mucosa to help kind of prevent dysphagia. I think another thing, Mason, I love your thoughts on this too, and I've always thought about this. It's like this concept of, you know, scarring is irreversible, and that's, you know, Stritta came and went. Like, you, you referenced it, just concept of just, you know, burning things. And, you know, there's no kinda fine-tuning the burning, you're just scarring it down, and whatever the body does is what it is. So I think there's kinda that, that question mark there. And the last thing I'll say is that I think, you know, certainly the reason that, that TIF got kind of a bad name out of the gate was, you know, doing these things in people that had hernias or that it wasn't indicated for. So just remember, if this is anything more than, like, a GE junction problem, if there's a big hiatal defect there, that, that's gonna have to be fixed. Speaker 2: Yeah. Thanks. Those are great points. And, and I, I have to admit, though, what I'm currently doing is probably, is a little bit different than the way this is described now. And I [00:07:00] think, um, you know, to your point with the stricturing and dysphagia, you do wanna be at least a centimeter away from the Z-line. Um, you know, I think it's kinda, I, I don't know if that first patient Dr. Inoue described needed a dilation at some point, but that's classic to, uh, you know, classic setup for a stricture and dysphagia. Um, so if you get too close to your Z-line, you're just gonna scar down the, the bottom of the esophagus and get a stricture. And then on that point, you know, I was thinking about the anatomy of that area. On the greater curve side is your mucosal flap valve, and looking up beyond that, you're actually, it's really at the level of the lower esophageal sphincter. Um, so I've actually modified my approach a little bit, and I, I do ARMA in the GI lab. It takes 10 minutes under MAC. It's very easy and fast. Um, but I just do, like, a big horseshoe on the greater curve side, and I'm picturing it kind of squeezing the LES from the outside. Um, so I probably leave a little bit of a bigger strip of spared mucosa on the lesser curve side, and then I have a big band coming around the backside. Um, and that seems to be working pretty well. [00:08:00] We haven't written that up yet or anything, but, um, personally I like that approach. Speaker 3: I mean, it kind of makes sense, too, when you think about, I mean, a lot of people and their fundoplications and, and then all that, like, GERD STOP device, it's all that emphasis kind of on like angle of His, greater curve tightening. You know? So I, I think that that's pretty in line with that, Mason. You're probably onto something there. Speaker 2: Yeah, I think that is important, re- recreating that flap valve. So you're almost, you know, scarring down angle of His there to, to make a nicer flap valve. Historically these procedures were thought of to, you know, essentially equivalent. Um, I think the most recent data does suggest ARMA might have a slightly higher success rate, which is interesting. No, you know, necessarily explanation for that, but you know, again, I think it's easier and faster to do anyway, so it's probably gonna take over over time. Uh, there is a more recent system, or, you know, actual systemic review and meta-analysis that shows 97% of the time the procedure's completed, and 80% of the time it's clinically successful. In our own practice, we consider that being able to get someone off of PPIs, and [00:09:00] we see about an 80% success rate uh, as well. Speaker: Do you guys find that you're seeing a lot of patients in your clinic who are interested in primary endoscopic therapies for management of reflux? Is this something that you get a lot of? Speaker 2: No one knows it exists, at least is my impression. So at least the, some of the GIs referring to me are aware of this now, and I get referrals specifically for that, and they've already discussed it with the patient, which is nice. So sometimes they come in knowing what we're gonna talk about. But usually I bring it up as a, you know, al- alternative to surgery, and they're thrilled to hear that there's another option. Speaker: Yeah, and I think, you know, one of the things that we, um, should reemphasize is that we're not saying that the data would support this being superior to fund application, but it really doesn't burn much of a bridge. And if you need to go back and do surgical intervention at a later time, um, you certainly can. But like, Mason said, like a 10-minute procedure literally, um, and I think, you know, this is just hypothesizing, but with the Arma it's, it's very straightforward. [00:10:00] Like, even people without really advanced surgical endoscopy skills, um, can complete the procedure and do so safely. So, and it's very reproducible, so that's probably why it works so well. But that was r- really good to hear from you, uh, Mason, about that. Next topic, uh, we've touched on this in prior episodes but really haven't described it, uh, in its full extent. Um, but the per oral plication of the esophagus or the POPE procedure, so this is esophageal plication. Trevor, would you tell us a little bit about this? I know you've written papers, as has, uh, Dr. Hedberg, um, on this topic, but love to hear how you use this in clinical practice. Speaker 4: Yeah, absolutely. So kind of for starters the POPE procedure, what is it and what do we use it for? Um, like you alluded to, basically this is endoscopically suturing a defunctionalized esophagus or gastric conduit with the purpo- the purpose of kind of reducing the redundancy of the lumen and hopefully improving their emptying and subsequently the patient's quality of life. [00:11:00] Um, and Mason was actually the first to write about this from our series, and that was several years back in the Journal of GI Surgery. It, Mason, were you the first? Was there someone who wrote it up before you here or in, like, the US or was your couple patients the first? Speaker 2: I think it was 2018, another group in California put out the first, like, video describing the technique, but we were not too far behind. It took me a couple of years to actually get the paper out, which Dr. Yujiki wasn't happy about, but we, we got it out eventually. Speaker 4: So, t- this is predominantly utilized in two distinct clinical scenarios, so with the same technical aspects, if you will. So one is in patients with end-stage esophagus after, like from either achalasia or after a myotomy, like in a blown-out myotomy syndrome. Uh, and also those with a dilated gastric conduit after esophagectomy Uh, so for the first of these patients with end-stage achalasia, this is basically the progression of disease, so when you have chronic untreated achalasia over time, and then the kind of converse to that is blown-out [00:12:00] myotomy, where you basically have a weakening of the esophageal wall, and this kind of patulous degeneration that happens over time after a myotomy. And so it's important to recognize that the accepted gold standard surgical alternative for achalasia patients really has been and is uh, an esophagectomy. And so this is obviously one of the most kind of complication-ridden procedures that we perform. And I think, you know, most people would quote complication rate at least at thirty or forty percent. And actually, when you compare, if you look side by side to patients who have esophagectomies for cancer, like all comers, and those who have esophagectomies for achalasia, because you have this chronic inflammatory process, it's actually a, a difficult, more difficult surgery, and it's, uh, complication-wise riskier, and the quality of life outcomes for achalasia specifically are not ideal. So when you're looking at selecting patients for this procedure for when you're working them up, typically they'll have a timed esophagram. Uh, it's particularly if someone's had a myotomy before. And so that will show you this kind of dependent area of the organ that can't drain well. That's what we kind of [00:13:00] refer to as the sump of either the distal esophagus or the neoesophagus. Um, and this ultimately becomes a target for the suture plications. So it should be noted that this is in the absence of a recurrent outflow obstruction. So typically, you would have done an endoscopic and/or like a flip impedance p-pelimetry evaluation to ensure that what you're seeing isn't just poor drainage from an incomplete myotomy, but that it is open and still geometrically unable to drain So with the POPE procedure endoscopic suturing is used to narrow the esophagus or conduit and kind of retubularize the organ to prevent the pooling of solids or liquid contents. Um, and so ideally you're, you know, reducing the patient's you know, their cause of their regurgitation and aspiration events and things. And so usually when performing this procedure- Thanks ... you, uh, will often want the patient on a liquid diet beforehand for at least a couple days. Even if you do that, a fair amount of times at the beginning of the procedure there's suctioning and removal of food particulate and things, and Roth netting, which can be fairly time-consuming. When you do the plications [00:14:00] themselves, so use an endoscopic suturing platform, typically you're gonna do kind of rows of sequential bites working distal to proximal, and you could do like a U-shaped pattern, much like, uh, we do in endoscopic sleeves and things. And then you're gonna anchor or cinch the stitches sequentially. And you're kinda visually gonna determine what anatomy approximates, quote-unquote, "normal" or ideal. And after the plications are finished, it's important to make sure you also can obviously drive through and haven't overly narrowed the lumen. Speaking of that, you know, uh, Mason, sometimes w- when we have a difficult post-myotomy case, a lot of times we'll temporize them or kind of revert to doing dilations. When you perform this procedure, do you always do a concurrent intervention like a dilation, or do you ever just suture in isolation? Speaker 2: Yeah, I, I, you know, I, I almost always do, and for two reasons. You know, we do use endoflip quite a bit in our practice, as you guys know. And you, you'll endoflip. So first I'll say kind of what patient are we doing this in. I, I've seen several like 90-year-old ladies who had their Heller myotomy 40 years ago, and they did well for a while, [00:15:00] and now it, it just looks like end-stage achalasia, where, um, they have the sump and things just aren't emptying very well. So even in that case, I mean, maybe things have scarred down and it's a little tight. Usually the endoflip isn't very impressive. You know, it's three or four DI, which we would consider, you know, adequate for a myotomy. Um, but even in that case, you know, they're in this situation with a dilated floppy esophagus. It probably got like that because of some degree of outflow obstruction. Um, it's possible just the organ is getting more flaccid over time. But the other reason I wanna, you know, relieve any kind of obstruction there is I don't want any pressure on my sutures. Um, and I think you're gonna touch on this later but, you know, sometimes these need to be repeated, and I feel like you're gonna extend the, the amount of time between each POPE you do if you, uh, really improve the, the emptying when you're there. So I, I usually use one of the 30 millimeter pneumatic balloons and just blow open the GE junction or the, the hiatus if it's a conduit, um, and then do the POPE to really tighten things up and hope it [00:16:00] doesn't stretch out again. Speaker 4: That's the real deal. That's like the Cadillac touch-up for endoscopic interventions. I love that. And so I, I guess that's is a good time to mention that, but it, it, this is really not kind of like a, a one-shot chance. If you need to perform the procedure again, which has certainly been done, uh, in, in our series and, and others, um, you definitely can, and patients can get serial relief. In Dr. Ujiki's contingent, we published the results of patients with this procedure and found basically that you can do it successfully 100% of the time, and that the vast majority of the time patients have improved or, or, or totally resolved symptoms at, at least at initial follow-up. Again, that kind of, that wears off over a period of, of, uh, late months to years. Interestingly, um, this procedure seems to be slightly more effective for patients with achalasia than those with gastric conduits, and that could be something to, you know, to the effect of when we're doing a gastric conduit, we skeletonize the, you know, the entire hiatus basically, and pull the stomach up in a totally, you know, atypical way from where it usually sits natively as opposed to the achalasia esophagus, which is [00:17:00] unchanged. In that series, there are basically no patients with achalasia who require esophagectomy, and so there are, uh, while that's very encouraging and continues to be encouraging as these procedures are repeated, certainly there are some, you know, definitely worth mentioning unknowns. Like, is there a point of futility at some point where you've sutured somebody multiple times? And what is it like to do an esophagectomy in someone who's had their esophagus sutured several times with full thickness bites? So, um, it's an interesting procedure and definitely something to watch out for over the next couple of years, but we will see. Speaker 2: Hey, you know, we talk about this overstitch device, um, with the Helix, where you're drilling through the tissue and you're pulling it into the, the device to take your bite of suture. This, this procedure always makes me a little nervous, because you're working right next to the aorta and the pericardium. There's some important structures right around you, uh, so you need to be very careful not to drill in too deeply with that device or really pull the tissue into the, into the overstitch before you take your bite. Speaker 3: Use a grasper, Mason. Speaker 2: You could. I mean, that, you know, I wonder too, we, we talked about the cirrhosis approximation in the stomach for an [00:18:00] endoscopic s- sleeve. That's what makes it durable. So you, you know, ideally you're getting all the way through the organ. But you gotta be very careful to do that, otherwise it'll, you know, you'll be back doing it again. Speaker 4: Is it a normal working channel size in the suturing device? You could put any instrument through it? Speaker 3: Yeah. So my ESGs are all we don't use the Helix. Really? Oh, Speaker 4: really? Oh, tell me more. Do you like it? Speaker 3: Well, it's faster. Harder to get full thickness, but, uh, safer. Hmm. So I think, you know, when, when you're doing it in the context I'm doing it, which is, you know, a big company of people doing a lot of ESGs with a lot of different skill levels, I think that's part of it. Also like this, it, you know, the Helix takes a lot of time. Screw, unscrew, gets messed up, gets caught, and we found that it, you know, if, if you pull in and, and take your bites and you're desophleting, you can easily get full thickness just with graspers. So we, we use a, a very bad, cheap set of graspers, but it works. Speaker 2: I can't wait for the randomized trial. That's gonna be a, you know, change a lot if that's works just as well Speaker: Yeah, I feel like every time this [00:19:00] is presented at like a meeting or talked about in a conference, people, you know, always kind of poo-poo the potential durability of this, especially since, you know, esophagus doesn't have cirrhosis, and we always talk about how that's the kind of the strength for a procedure like ESG. But I really think it's the flip side, and I know Mason, you and B- Trevor both mentioned this. It's like you can bring these people back and keep doing that, right? Like, if it has some temporary relief. So I know there's, uh, w- at least one or two patients with you, Mason, that you have done multiple times, um, and these people have, have found that at least temporarily provides some real symptomatic improvement. Speaker 2: Yeah, I mean, that series is small. I got, I got one guy who had a POM, you know, a couple decades ago. He's one of the first, like when Dr. Swanstrom was doing them in France. But so we did him every year for the last three years, but each time we gained a couple months. So it's getting-- The interval is expanding a little bit each time. So I wonder, you know, as long as you don't wait too long, and the organ is all the way floppy again, you can keep cinching it up, and you [00:20:00] manage to get some scarring and more durability over time. Speaker 3: You guys think anyone's gonna start stapling these? Like, just surgically? You know, like, what's the difference? Speaker 2: That you gotta go into the chest. I mean, I've done one of those where this didn't work. Um, that's a really hard surgery. Speaker 3: You've done one? Speaker 2: I did one with one of our thoracic surgeons, Dr. Su. Um, we tried multiple, you know, endoscopic interventions. It was a post-esophagectomy conduit. Just couldn't get it empty. Um- Oh ... she went in, we dissected it all out, and she stapled off the redundancy. But, you know, you gotta m- make sure you know your vascular anatomy really well. If you staple in the wrong place, you kill the conduit. So it's, it's a little risky. Speaker 4: How'd he do? Speaker 2: Uh, it went fine. Speaker: Interesting. It's just a challenging problem. Speaker 2: Very challenging, yeah. Speaker: It is. Well- Speaker 4: Yeah, I, I do, like, know esophagectomies in my own practice, so the, this has totally trailed off for me as far as patients. I, I rarely see patients that are good candidates for POPE. But it's interesting, because I think the other thing [00:21:00] that people don't talk about at meetings is, like, when you have a s- you know, make up a clinical scenario, a 75-year-old person who comes in with esophageal cancer, really bad problem, really a bummer to get an esophagectomy, but, like, the right thing to do. When you're talking at, like, a 34-year-old young person about getting an esophagectomy, that's a really tough conversation. Like, as a, when you move to the staff level and start talking to people about that, that's, like, a really hard thing to sell someone on doing. So to have anything that's, like, a, you know, this is, you know, maybe we don't know if this is a temporary break or a full fix, like, it's a, it's an, it's promising. Speaker: Yeah, it's funny, my take would be a little bit different. The younger person might be able to tolerate it, but the- Oh, sure ... Speaker 4: 75-year-old Yeah, that's, that's fair enough. Fair enough. Speaker: Yeah. Interesting topic though, guys. So the next one, um, the next thing we're gonna talk about, um, I actually had a patient ask me about in clinic, and kind of, like, stuttered my way through my, um, understanding of it. So, I'm bringing this up to educate myself as much as, uh, the listeners here. But [00:22:00] it's duodenal mucosal resurfacing. So are any of you doing this routinely in practice? No? Okay. I think it definitely is worth mentioning though, um, because it is gaining some popularity in s- in particular in GI circles. Um, but it's an endoscopic procedure that's based on the concept that the duodenum plays an important role in glucose control and homeostasis, and that the actual resurfacing of a portion of the duodenum can help reset some of the signaling that's related to glycemic control. So really most of the data here is based on, um, improvements in glycemic control and A1C over time rather than weight loss. But, um, some of the studies out there have showed a mild degree of weight loss in addition to improvements in glucose metabolism. Um, so specifically with the duodenum, it's a nutrient sensing and critical in iron absorption, um, which helps to regulate, uh, the incretin effect and influences insulin secretion. So a typical, uh, patient for this procedure would be a type 2 [00:23:00] diabetic not adequately controlled on oral medications. Um, and with DMR, you advance an endoscope into the duodenum uh, beginning distal to the ampulla And you a-advance a DMR device over a guide wire and then use a catheter to actually lift the mucosa of the duodenum and then, uh, perform thermal ablation. So obviously anytime you're ablating a portion of the gastrointestinal tract, there is the, um, r-real risk for perforation. Um, and then the ablation is usually carried about 10 centimeters distally, uh, to where you'd start. Um, common contraindications for a procedure like this are things that are pretty intuitive, so things like duodenal ulcer disease or inflammation for altered foregut anatomy, so patients who have had a prior bypass or any sort of active GI bleeding. But systematic reviews of this procedure actually show that it's fairly effective, um, in reducing A1C by about a point to a point and a half over, uh, six months, uh, with effects often [00:24:00] durable at a year. Um, and again, like I said, modest weight loss, so within six months to a year at typically around, um, 10 pounds. But like other things that we talked about in the endobariatic, um, episode, this can be combined with medication and lifestyle modification, um, to produce somewhat durable weight loss results. There's an adjacent technology, um, one I think I tried to either convince, uh, Dr. Hedberg to participate in or not, I forget at the time called the RESET procedure, um, which is, um, somewhat similar to a traditional duodenal mucosal, uh, resection. Um, and the procedure's performed in a similar manner. Um, however it doesn't, uh, involve thermal ablation. Um, and so there's no, um, saline lift that's required for the procedure. Rather, um, it has to do with electroporation, um, uh, basically applies that along the same surface of the, uh, duodenum. Um, but given the prevalence of diabetes, um, and metabolic syndrome, um, [00:25:00] that, uh, continues to be on the rise, these are potential promising, uh, treatment options for patients. Um, and these are procedures that are performed as outpatient, um, with some dietary modification, typically over a couple of weeks postoperatively, um, but appear to be, you know, well-tolerated as long as you know what you're looking at. But, um, resurfacing I think will get a lot more scientific attention in the coming years. I think something that is worth talking about is something that's a little bit tangential to this. But you know, Mason, um, as the mad scientist that he is, um, has developed a somewhat novel application for this for patients who have In the stomach, had a prior bypass, and are still having acid reflux-type symptoms. So, Mason, you wanna talk about that a little bit? Speaker 2: Yeah, happy to. Thanks. You know, acid issues after a bypass, you know, we're, we're taught that you know, bypass is a really good anti-reflux operation because most of the acid production is distal in the stomach and gets excluded. Um, but depending on what you [00:26:00] read, up to 15% of patients after a bypass can have enough acid production in the pouch to actually have abnormal pH testing, um, which goes along with symptoms of heartburn, but also marginal ulcers. So if you have someone with heartburn, there's no great options. You know, they could do a LINX. Some people have described using the remnant stomach as a fundoplication. Um, you can't really retroflex in the right size pouch to do an Arm or Arms. But the v- volume of the pouch is so small, the thinking was, why don't we just ablate where the acid production most likely is and decrease the production in the pouch? Uh, so there is an animal study out there that shows after you ablate gastric mucosa, the parietal cells don't grow back. Um, that was kind of the foundation for the thinking at least. And the first patient I found where I thought it would be appropriate is someone who had a really bad marginal ulcer for years, had been on every kind of antacid therapy, and this thing would just not heal. And we're also taught that this could be an ischemic problem, so you could redo the anastomosis, [00:27:00] which is also a big deal. So we talked about doing an ablation to see if we can get this ulcer to heal, and it worked great. The, the ulcer healed. Um, so we've done a couple serie- or a small series now. I think there's an abstract in DDW from last year or this year where we have a couple patients who we did it for GERD, and the pH test showed improvement after the ablation. Um, and then we've-- usually we're looking at, uh, non-healing marginal ulcers, and that seems to be where it kind of shines. The way to figure out, you know, I'd love to have a, I want, what I really wanna do is talk to Cook Medical and replace their HemoSpray anticoagulation device, or excuse me, coagulation device, uh, with like a Lipnis powder so you can blast it in the pouch and see where the acid production is. Kind of the, you know, cheat approach we use for that right now is if a patient's not on PPIs when you're, uh, doing the procedure, you can take little random biopsies, and there's this reaction where when blood hits acid, it turns brown or dark, and you can actually see in the pouch where the acid production is based on these tiny little biopsies.[00:28:00] And as expected, it's usually distal around the GE junction or the lateral, so we target those areas and, you know, see if, you know, just go by symptoms most of the time. We've had a couple where we repeat the pH testing. Speaker 3: But sorry, Mason, so just, and you kind of just touched on it, but so with these marginal ulcers, y- y- you're just, you're bleeding just the, the proximal mucosa? Is that kind of the gist? Speaker 2: Yeah, in the pouch. So we stay away from the actual ulcer on purpose. Right. Don't want to ablate around there. But we do it the same way as an arm, an Armo. So we lift, you know, use little biopsies, figure out where it's turning brown, lift, and then ablate that area. Um, and again, the volume, you know, the surface area in that pouch is small enough that, you know, even if you're hitting about 10 or 20% of the pouch, if that's where most of the acid production is, it's gonna take care of it. Speaker 3: I mean, Mason, that's a really big deal. So I, I've done a handful of these like kind of GJ refractory ulcer, like surgical revisions and, and they're br- I mean, my complication rate's 100%. Like it, they're, they're hard. The, the ulcer is scarred into like the pancreas and the SM. I mean, they're miserable cases. So if you're [00:29:00] telling me that I can go argon someone and maybe avoid that, I, I'm in, man. I would definitely try that. Speaker 2: Yeah, no, I, I've done one, and that was part of the reason I was thinking about it. You know, they're really tough cases, and it's an acid problem. You know, you can decrease the acid production pretty easily. Speaker 3: Well, that tracks too, because I, you know, I do vagot- in the few I've done, I would do vagotomies in, in those patients as well. And there's, you know, people talk about, you know, the G cells being the antrum, but you know, the oxyntic cells are, are all over the stomach, particularly in body and can totally be in the gastric pouch. So it makes sense to, to target that. Speaker 2: Yeah. Speaker 4: I have a related clinical scenario that I was wondering. It, it strikes me this is close, and maybe you guys would have some insight. I've got a lady who had a bypass who's been doing what, who did well for a while. Her weight is fine, but she has severe, like classic heartburn symptoms. Has a two, like a sliding hiatal hernia, basically small, probably there beforehand, but not seen during surgery, has upper GI evidence of such and, and, you know, refluxate going up her [00:30:00] esophagus. And manometry with w- to spare everyone the details, probably IEM, and had that before surgery, and it like dysphagia pre and post-op. Is there, do you have any options for this patient, someone who doesn't qualify for a LINX, doesn't have the motility for LINX or Arma? Is this something, do, do you any purpose for this kind of procedure of ablating the gastric pouch mucosa? Speaker 2: It's pr- you know, I, I usually end up needing to fix the hernia in that scenario. Yeah ... if it's small, I mean, that's half the pouch probably. But you could... Do- are- do PPIs help? Speaker 4: Yes, they do. Terrible symptoms off PPI for, for testing. Speaker 2: Yeah, so you could try it. You know, it might be good enough if PP- if it's acid, you know, responsive to antacids, it's probably worth a try. But if it doesn't work and it's, like, still refluxing fluid that's uncomfortable, then you just gotta fix the hernia problem. Speaker 4: And you just go in isolated, do just a hiatal hernia repair? Speaker 2: Yeah, I think, um, you know, if you could, if you're going to the OR first, you could do the vag- truncal vagotomy and a hernia repair. Okay. Might take care of the acid [00:31:00] problem as well. Yeah. Speaker 4: Make sure the pouch is small, I guess. Speaker 2: Yeah. Speaker 4: Yeah. Speaker 3: You know, vagal nerves are funny. When, when you're trying to cut them, they're hard to find. But conversely, um, and I just wanna state, just 'cause I harp on this in my residency, obviously, Trev, you, you, you would bravo this patient first- Yeah. Yeah, yeah ... or actually prove that they've, you know, an upper GI certainly is not sufficient, but- Yeah, yeah I'm sure you guys already did that. Speaker: Yes. Speaker 3: All right. I'll just kick in. So I'm, I'm pretty excited to, um, talk about this next topic, which is basically magnetic-facilitated enteric anastomosis. Um, so this isn't something I, I, I certainly do, and it's not something I knew much about before preparing for this, but, um, so the, the term is called magnetomosis, which I'm, I'm fairly certain that Sully invented that term. But more commonly what I've seen is a magnetic compression anastomosis, or MCA. And obviously this is not gonna be all-encompassing, but I do just wanna kinda introduce this topic 'cause I, I, I think it's gonna be becoming more popular as time goes on. I will say, I feel like I've been hearing about this for, like, 20 years. I feel like we've been in, like, the same developmental phase for, like, 20 years. You know, the [00:32:00] videos are all from stages from 2018 and '16, so I do think it's interesting that it's not more mainstream. But the concept here is that the magnetic anastomosis works where you're placing tissue between two magnets, and then those magnets attract and the, the tissue dies basically, and over time an anastomosis forms. And then, you know, people just pass the magnets, and 'cause it's two magnets stuck together it doesn't, you know, cause any trouble. And th- there's a few advantages. Um, one of them is... So one of them is that you know, i- if they're properly aligned, it, it, it can avoid a surgical anastomosis, so, so no suturing, um, anything like that. And then, it, the, the anastomosis that's made is reproducible, so it's kind of the same size. It, it's, uh, to a fit dimension and, and, and that's obviously a benefit there. And to this point it's most often described as a hybrid approach. So basically there's a magnet in the proximal part of the GI tract which is placed endoscopically. But then the distal magnet is placed laparoscopically, robotically, basically inserted through an enterotomy, which is then closed. So last year, one of the top papers at ASMBS, it looked at 19 human patients who underwent a duodenoileal [00:33:00] anastomosis in conjunction with a sleeve gastrectomy. They, they called this a SNAP-S. Um, I forget what it stands for, but I thought that was pretty cool. And they, they used a neodymium magnet, and it was advanced to the anterior portion, D1. And then they made basically a separate enterotomy in the ileum to place the second magnet. And there was no complications from the magnets themselves, and patients did really well from a weight loss perspective, so 31% total body weight loss, which is, it's about 78% excess body weight loss. And I, I've seen kind of a few other options just in, in looking at, at, at, at this, and, you know, there's options where patients swallow the magnets and then there's this, this little, like, putter device where you can actually laparoscopically, you know, guide the magnet kind of through the small bowel. And I, I definitely, um, y- I, I was able to actually pull this paper. And as someone in private practice, I rarely actually have full access to read the whole paper, so I got to review it. And I was looking at some of the complications. You know, I mentioned that there was no magnet related, but- One of the ones was actually someone who got really bad cholecystitis after weight loss, and they underwent a, a lap chole, and sure enough, had a cystic duct stump leak, [00:34:00] which in someone that had, you know, a true duodenal switch, that's a huge problem, right? Because you can't go past D1, whereas in this scenario, you're, you know, you're not necessarily closing the door to the rest of the duodenum. So they were able to do an ERCP and put a stent in. So I kind of thought that was another, um, benefit. My other problem with this, you know, I, you hate to see that, you know, they're making a hole in the small bowel just to put a magnet in. You know, I think in a surgeon's hands, if you're gonna make a hole in the small bowel, you might as well just do the anastomosis. But certainly you can see how different applications would be useful. And, and as I talked about, you know, the, the concept of doing a completely endoscopic anastomosis, it's been described and the issue is, you know, deploying that distal magnet and getting it to the right place. Certainly the magnet's not gonna stop necessarily where you want it to. Another place that I've seen this is people with gastrointestinal obstructions. So if someone has a really severe gastrointestinal obstruction, it's been described to, to do, you know, two scopes. And same thing, you have to make some sort of enterotomy in the small bowel and go back proximally, but basically deploying two magnets. Then over time, those, those, those lumens [00:35:00] oppose it, and then there's ischemia and, and, and then you have a connection. Um, so certainly I, I think it's a cool idea. I will say as, as someone that, you know, has done quite a few gastrojejunostomies for gastrointestinal obstruction, oftentimes those stomachs don't empty anyway. So to think that, you know, they're gonna magically empty through the small magnetic anastomosis, I'm, I'm not so sure. Right. But, um, but so it goes. But that's, that's kind of it. The, the other thing that came up was, um, people with severe biliary strictures. So I've seen where, um, you know, they'll basically through a PTBD place a magnet proximally and then do an ERCP and place a, a magnet distally and, and over time this can kind of erode and create an anastomosis. But some really cool stuff. I don't know. What about you guys? Any, any cool things that you're seeing in the future of endoscopies as it relates to, you know, primary endoscopic therapies? Speaker 2: Yeah, I have heard of, I mean, we- we're probably all familiar with using the Axio stent to make, uh, anastomoses. I mean, the one benefit of that is you can just get your hole right away. You know, in these scenarios with the magnets, I, I don't know, do you-- did you come across how long it takes for the anastomosis to actually form? It's [00:36:00] probably at least a month, would be my guess, but- Speaker 3: Y- yeah, certainly weeks, and there's a few different devices. There's some that actually have the anast- like a small version of the anastomosis, and then like the magnet is gonna create a bigger anastomosis. So obviously in that case, some of it's instantaneous. Speaker 2: Yeah, so you can like punch a hole in the center of it to, you know, I see. Speaker 4: Did you make up the word neodymium? Is that an element on the periodic table? Neodymium. Neodymium. Speaker 3: I think it's like allomantium. Yeah. No, I didn't make it up. So it is, you know, that's, that's from the company. Speaker: And apparently Zach's been hearing about this for 20 years. He's much, um, older than us. Speaker 4: He's Speaker: got Speaker 4: stock in neodymium mines, yeah. Speaker 3: I will say, if you can pull up some videos, there's really-- the way the magnets are deployed endoscopically is really, really cool because it, you know, it comes out linear and then it kind of, you know, curls around like a finger almost, then creates an octagon. Um, so it-- there's someone, probably Mason-level smartness, uh, came up with the concept. Speaker 4: I-- One thing that occurred to me, and, and I don't know that this matters for today's discussion, but that kind of procedure, specifically for a SADI, if you think about a [00:37:00] surgeon learning that technique, par- particularly a surgeon without a robot, doing the dissection behind the duodenum and then doing a, a hand-sewn like duodenal ileostomy basically is like an inc- it's a difficult skill to learn. But to be able to do an enterotomy and put a magnet in and then kind of use a wand to fish them together, the learning curve would be way smaller. Like your, your access to, like accessibility to surgeons to be able to do this as a learned procedure is that, that's incredible, especially for a place that doesn't have, you know, a robot with the degrees of freedom and things like that. Speaker 3: 100%. I mean, that is the hardest part of that. That's the two hardest parts of that case. And I know I was complaining about making an enterotomy to place the distal magnet, but they, th- in that paper exam- th- there's, it was a two millimeter enterotomy, like a two mil- th- just a tiny little thing that they just, you know, put a few stitches in. So d- definitely I agree with you, Trevor. I think from a technical component it's, uh, it's, it's interesting. Speaker: Zach, you wanna take us to the quick hits since you're on a roll? Speaker 3: Yeah. Sure. All right, guys, uh, no more comments, [00:38:00] then, uh, time for the quick hits part of the episode. Um, so the Arm/Armor procedure represents primary endoscopic therapies for the management of gastroesophageal reflux disease. Two, endoscopic suture plication of the esophagus or neoesophagus can help promote emptying in patients with dilated esophagus form achalasia or gastric conduit, uh, following an esophagectomy. Three, um, such esophageal plication with the POPE procedure may be performed more than one time and help negate the need for esophagectomy in patients with end-stage achalasia or blown-out myotomy. Four, duodenal mucosal resurfacing represents a promising endoscopic therapy, particularly for enhanced glucose control in which hydrothermal ablation is used to ablate the duodenal mucosa. And lastly, number five, in the future, magnetic compression anastomosis may become more common and may be preferred in a hybrid laparoscopic fashion, and have already been done completely and, uh, endoscopically. Speaker 2: Awesome. Well, thank you so much for listening to this episode. Please be sure to check out the accompanying videos on the website, and make sure to tune in to our final episode in the series where [00:39:00] we discuss biliary endoscopy. For now, this is the BTK Surgical Endoscopy team reminding you to dominate the day.